DEPARTMENT OF INSURANCE
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DEPARTMENT OF INSURANCE
STATE OF NORTH CAROLINA
FORM E
PRE-ACQUISITION NOTIFICATION FORM
REGARDING THE POTENTIAL COMPETITIVE IMPACT
OF A PROPOSED MERGER OR ACQUISITION BY A
NON-DOMICILIARY INSURER DOING BUSINESS IN THIS
STATE OR BY A DOMESTIC INSURER
GENERAL INSTRUCTIONS
Transactions subject to North Carolina General Statute (“G.S.”) 58-19-15(a) may not be entered into unless the acquiring person has submitted a pre-acquisition notification with the Commissioner on a Form E.
Form E is a guide to be used in preparation of the notification required by G.S. 58-19-15(f); it is not a blank form to be filled in. A Form E statement is attached.
Detailed instructions for the preparation and filing of a Form E statement are contained in G.S. 58-19-15, G.S. 58-19-75, G.S. 58-19-80, G.S. 58-19-85, and G.S. 58-19-90.
DEPARTMENT OF INSURANCE
STATE OF NORTH CAROLINA
FORM E
PRE-ACQUISITION NOTIFICATION FORM
REGARDING THE POTENTIAL COMPETITIVE IMPACT
OF A PROPOSED MERGER OR ACQUISITION BY A
NON-DOMICILIARY INSURER DOING BUSINESS IN THIS
STATE OR BY A DOMESTIC INSURER
_______________________________________________________
Name of Acquiring Person (Applicant)
_______________________________________________________
Name of Other Person
Involved in Merger or Acquisition
Filed with the Insurance Department of North Carolina
Dated _____________, 20____
Name, Title, Address and Telephone Number of Individual to
Whom Notices and Correspondence Concerning this Statement
Should be Addressed:
________________________________________
________________________________________
________________________________________
________________________________________
ITEM 1. NAME AND ADDRESS
State the names and addresses of the persons who hereby provide notice of their involvement in a pending acquisition or change in corporate control.
ITEM 2. NAME AND ADDRESSES OF AFFILIATED COMPANIES
State the names and addresses of the persons affiliated with those listed in Item 1. Describe their affiliations.
ITEM 3. NATURE AND PURPOSE OF THE PROPOSED MERGER OR ACQUISITION
State the nature and purpose of the proposed merger or acquisition
ITEM 4. NATURE OF BUSINESS
State the nature of the business performed by each of the persons identified in response to Item 1 and Item 2.
ITEM 5. MARKET AND MARKET SHARE
a) State specifically what market and market share in each relevant insurance market the persons identified in Item 1 and Item 2 currently maintain in that state.
b) Provide historical market and market share data for each person identified in Item 1 and Item 2 for the past five years and identify the source of such data.
c) Provide information to support whether the proposed acquisition or merger, if consummated, would substantially lessen competition.
If the proposed acquisition or merger would substantially lessen competition, provide justification of why the acquisition or merger would not create a monopoly in the state.
For the purposes of this item, market means direct written insurance premium in this state for a line of business as contained in the annual statement required to be filed by insurers licensed to do business in this state.
ITEM 6. SIGNATURE AND CERTIFICATION
Signature and certification on the attached form.
SIGNATURE
Pursuant to the requirements of North Carolina General Statute 58-19-15,
__________________________ has caused this Statement to be duly signed on its behalf in the
(Name of Applicant)
City of _____________________ and State of __________________, on the _______ day
of ___________________, 20 _____.
(SEAL) ________________________
(Name of Applicant)
By ________________________
(Name)
________________________
(Title)
Attest: _____________________________________
(Signature of Officer)
_____________________________________
(Title)
CERTIFICATION
The undersigned deposes and says that (s)he has duly executed the attached Statement dated
the _______ day of ______________, 20 ________, for and on behalf of
______________________________________ that (s)he is the ____________________
(Name of Applicant) (Title of Officer)
of such company and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
Signature ________________________
Type or Print ________________________
................
................
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